Christopher C. H. Cook

Evaluation of Techniques for the Quantification of Myocardial Scar of Differing Etiology Using Cardiac Magnetic Resonance

OBJECTIVES The aim of this study was to compare the reproducibility of 7 late gadolinium enhancement (LGE) quantification techniques across 3 conditions in which LGE is known to be important: acute myocardial infarction (AMI), chronic myocardial infarction (CMI), and hypertrophic cardiomyopathy (HCM). BACKGROUND LGE by cardiac magnetic resonance is the gold-standard technique for assessing myocardial scar. No consensus exists on the best method for its quantification, and research in this area is scant. Techniques include manual quantification, thresholding by 2, 3, 4, 5, or 6 SDs above remote myocardium, and the full width at half maximum (FWHM) technique. To date, LGE has been linked to outcome in 3 conditions: AMI, CMI, and HCM. METHODS Sixty patients with 3 LGE etiologies (AMI, n = 20; CMI, n = 20; HCM, n = 20) were scanned for LGE. LGE volume was quantified using the 7 techniques. Mean LGE volume, interobserver and intraobserver reproducibility, and impact on sample size were assessed. RESULTS LGE volume varied significantly with the quantification method used. There was no statistically significant difference between LGE volume by the FWHM, manual, and 6-SD or 5-SD techniques. The 2-SD technique generated LGE volumes up to 2 times higher than the FWHM, 6-SD, and manual techniques. The reproducibility of all techniques was worse in HCM than AMI or CMI. The FWHM technique was the most reproducible in all 3 conditions compared with any other method (p < 0.001). Use of the FWHM technique for LGE quantification in paired analysis would lead to at least a 60% reduction in required sample size compared with any other method. CONCLUSIONS Regardless of the disease under study, the FWHM technique for LGE quantification gives LGE volume mean results similar to manual quantification and is statistically the most reproducible, reducing required sample sizes by up to one-half.

Religion, spirituality, and mental health: current controversies and future directions.

Abstract Although studies examining religion, spirituality, and mental health generally indicate positive associations, there is a need for more sophisticated methodology, greater discrimination between different cultures and traditions, more focus on situated experiences of individuals belonging to particular traditions, and, in particular, greater integration of theological contributions to this area. We suggest priorities for future research based on these considerations.

Genetic linkage analysis supports the presence of two susceptibility loci for alcoholism and heavy drinking on chromosome 1p22.1-11.2 and 1q21.3-24.2

BackgroundIn order to confirm a previous finding of linkage to alcoholism on chromosome 1 we have carried out a genetic linkage study.MethodsDNA from eighteen families, densely affected by alcoholism, was used to genotype a set of polymorphic microsatellite markers at loci approximately 10 centimorgans apart spanning the short arm and part of the long arm of chromosome 1. Linkage analyses were performed using the classical lod score and a model-free method. Three different definitions of affection status were defined, these were 1. Heavy Drinking (HD) where affected subjects drank more than the Royal College of Psychiatrists recommended weekly amount. 2. The Research Diagnostic Criteria for alcoholism (RDCA) 3. Alcohol Dependence Syndrome (ADS) as defined by Edwards and Gross (1976) and now incorporated into ICD10 and DSMIV.ResultsLinkage analyses with the markers D1S1588, D1S2134, D1S1675 covering the cytogenetic region 1p22.1-11.2 all gave positive two point and multipoint lods with a maximum lod of 1.8 at D1S1588 (1p22.1) for the RDCA definition of alcoholism. Another lod of 1.8 was found with D1S1653 in the region 1q21.3-24.2 using the HD affection model.ConclusionThese results both support the presence of linkage in the 1p22.1-11.2 region which was previously implicated by the USA Collaborative Study of the Genetics of Alcoholism (COGA) study and also suggest the presence of another susceptibility locus at 1q21.3-24.2.

WPA Position Statement on Spirituality and Religion in Psychiatry.

The WPA and the World Health Organization (WHO) have worked hard to assure that comprehensive mental health promotion and care are scientifically based and, at the same time, compassionate and culturally sensitive1, 2. In recent decades, there has been increasing public and academic awareness of the relevance of spirituality and religion to health issues. Systematic reviews of the academic literature have identified more than 3,000 empirical studies investigating the relationship between religion/spirituality (R/S) and health3, 4. In the field of mental disorders, it has been shown that R/S has significant implications for prevalence (especially depressive and substance use disorders), diagnosis (e.g., differentiation between spiritual experiences and mental disorders), treatment (e.g., help seeking behavior, compliance, mindfulness, complementary therapies), outcomes (e.g., recovering and suicide) and prevention, as well as for quality of life and wellbeing3, 4. The WHO has now included R/S as a dimension of quality of life5. Although there is evidence to show that R/S is usually associated with better health outcomes, it may also cause harm (e.g., treatment refusal, intolerance, negative religious coping). Surveys have shown that R/S values, beliefs and practices remain relevant to most of the world population and that patients would like to have their R/S concerns addressed in health care6, 7, 8. Psychiatrists need to take into account all factors impacting on mental health. Evidence shows that R/S should be included among these, irrespective of psychiatrists’ spiritual, religious or philosophical orientation. However, few medical schools or specialist curricula provide any formal training for psychiatrists to learn about the evidence available, or how to properly address R/S in research and clinical practice7, 9. In order to fill this gap, the WPA and several national psychiatric associations (e.g., Brazil, India, South Africa, UK, and USA) have created sections on R/S. WPA has included “religion and spirituality” as a part of the “Core Training Curriculum for Psychiatry”10. Both terms, religion and spirituality, lack a universally agreed definition. Definitions of spirituality usually refer to a dimension of human experience related to the transcendent, the sacred, or to ultimate reality. Spirituality is closely related to values, meaning and purpose in life. Spirituality may develop individually or in communities and traditions. Religion is often seen as the institutional aspect of spirituality, usually defined more in terms of systems of beliefs and practices related to the sacred or divine, as held by a community or social group3, 8. Regardless of precise definitions, spirituality and religion are concerned with the core beliefs, values and experiences of human beings. A consideration of their relevance to the origins, understanding and treatment of psychiatric disorders and the patients attitude toward illness should therefore be central to clinical and academic psychiatry. Spiritual and religious considerations also have important ethical implications for the clinical practice of psychiatry11. In particular, the WPA proposes that: A tactful consideration of patients’ religious beliefs and practices as well as their spirituality should routinely be considered and will sometimes be an essential component of psychiatric history taking. An understanding of religion and spirituality and their relationship to the diagnosis, etiology and treatment of psychiatric disorders should be considered as essential components of both psychiatric training and continuing professional development. There is a need for more research on both religion and spirituality in psychiatry, especially on their clinical applications. These studies should cover a wide diversity of cultural and geographical backgrounds. The approach to religion and spirituality should be person‐centered. Psychiatrists should not use their professional position for proselytizing for spiritual or secular worldviews. Psychiatrists should be expected always to respect and be sensitive to the spiritual/religious beliefs and practices of their patients, and of the families and carers of their patients. Psychiatrists, whatever their personal beliefs, should be willing to work with leaders/members of faith communities, chaplains and pastoral workers, and others in the community, in support of the well‐being of their patients, and should encourage their multi‐disciplinary colleagues to do likewise. Psychiatrists should demonstrate awareness, respect and sensitivity to the important part that spirituality and religion play for many staff and volunteers in forming a vocation to work in the field of mental health care. Psychiatrists should be knowledgeable concerning the potential for both benefit and harm of religious, spiritual and secular worldviews and practices and be willing to share this information in a critical but impartial way with the wider community in support of the promotion of health and well‐being. Alexander Moreira‐Almeida1,2, Avdesh Sharma1,3, Bernard Janse van Rensburg1,4, Peter J. Verhagen1,5, Christopher C.H. Cook1,6 1WPA Section on Religion, Spirituality and Psychiatry; 2Research Center in Spirituality and Health, School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil; 3‘Parivartan’ Center for Mental Health, New Delhi, India; 4Department of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa; 5GGZ Centraal, Harderwijk, the Netherlands; 6Department of Theology and Religion, Durham University, Durham, UK

Interdisciplinary Approaches to the Phenomenology of Auditory Verbal Hallucinations

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) “front-loading” research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.

The D2 dopamine receptor gene and alcoholism: a genetic effect in the liability for alcoholism.

Three of five recent association studies have demonstrated an increased frequency of the A1 allele of the TaqI Restriction Fragment Length Polymorphism (RFLP) of the DRD2 locus in alcoholics compared to controls. One of three family studies has shown preliminary results in favour of linkage of this locus with alcoholism and heavy drinking. The possible mechanism of a genetic effect of the DRD2 locus in alcoholism remains open to speculation, but many involve personality characteristics such as impulsiveness or spontaneity. The applications of the findings of research in this field offer much potential for the prevention and treatment of alcoholism, but also raise certain ethical issues when applied to screening programmes. Future research will be assisted by the development of new, and more informative, genetic markers which are now available at this locus.

Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

The extent to which religion and spirituality are integrated into routine psychiatric practice has been a source of increasing controversy over recent years. While taking a patients spiritual needs into account when planning their care may be less contentious, disclosure to the patient by the psychiatrist of their own religious beliefs or consulting clergy in the context of treatment are seen by some as potentially harmful and in breach of General Medical Council guidance. Here, Professor Rob Poole and Professor Christopher Cook debate whether praying with a patient constitutes a breach of professional boundaries in psychiatric practice.

Suicide and religion

Much of the evidence that religion provides a protective factor against completed suicide comes from cross-sectional studies. This issue of the Journal includes a report of a new prospective study. An understanding of the relationship between spirituality, religion and suicide is important in assessing and caring for those at risk.

The genetic predisposition to alcohol dependence

Genetic effects from the aldehyde dehydrogenase gene localised on human chromosome 12 have been shown to have a major effect on the development of alcoholism in Far Eastern populations. This effect is caused by a point mutation in an exon of the aldehyde dehydrogenase gene which inactivates the enzyme, is dominantly inherited and effectively divides the population into those at risk and those at very little risk of developing alcoholism. This metabolically induced aversion to alcohol has not been shown in white European populations but it is likely that the alcohol dehydrogenase genes on chromosome 4 affect some aspects of alcohol consumption both in the Far East and in European populations and that the dopamine D2 (DRD2) gene also plays a part in a subgroup of individuals. The human genome project and recent genetic linkage studies have brought us to the threshold of a much deeper understanding of how genetic and environmental factors interact in alcoholism. The well known clinical observation of comorbidity of alcoholism with anxiety, depression and antisocial personality will soon be understood in the context of genetic effects from specific genetic susceptibility loci. This genetic research will reinvigorate clinical epidemiology by helping to identify environmental factors much more accurately and will enable both improved treatment and prognosis, Curr Opin Psychiatry 12:269-275.

The faith of the psychiatrist

Research suggests that spirituality and religion are significant variables contributing to mental well-being and that they can also play an important part in the treatment of mental disorders. The present paper reviews studies which show that psychiatrists are less likely than their patients to report religious affiliation. While mental health service users report that they wish spirituality to be addressed during their treatment, psychiatrists appear to be more divided as to whether spiritual or religious matters should be addressed within routine clinical enquiry and treatment planning. However, psychiatric practice itself might be understood as requiring a kind of faith, albeit not religious, within which basic principles of clinical care are accepted by virtually all psychiatrists. It is also clear that explicit religious faith (of the patient and the psychiatrist) does potentially have an important impact on the clinical consultation, whether for good or for ill. There is a need for guidelines to govern the ways in which this impact might most effectively be managed, both ethically and therapeutically.